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Failure to thrive.

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Hello, I am a nurse and this question is about a patient's case that has been bothering me for a long time. Pt was admitted with nausea and vomiting and failure to thrive. He had severe protein calorie malnutrition. History: diabetes, R leg amputation, (huge!) stage 4 pressure ulcer on back/sacrum, ileostomy, urostomy. His body was very swollen from fluid exudation and MD wanted to place a PEG tube to correct the malnutrition but pt refused. He was on a clear liquid diet but not eating much d/t poor appetite and nausea. When I cared for him he had just had his PU surgically debrided and was getting narcotics for pain. He was still nauseous and vomited once, a small amount of clear fluid. His abdomen was slightly distended but not painful and with bowel sounds. He had an EGD that did not show anything, but a previous KUB had showed bowel wall edema. The MD came to examine him and was aware of the distension and continued nausea. At the end of the shift I did my I and O totals and found his ileostomy had only put out about 150 mls in 12 hours. I reported this to the oncoming shift and they charted the 24 hr total (200 mls) in the AM. The next day the MD reviewed the chart and saw the low output, plus pt's abdomen was more distended. He ordered a KUB to rule out ileus and advised us to stop giving pt narcotics. The KUB was scheduled for the next morning but that night around 3 am pt complained of sudden severe pain and an extremely distended abdomen. Night nurse called the MD twice to request an NG tube and suction but MD said to just stop the narcotics and he would examine the pt in the AM. The patient began vomiting and ended up aspirating and then coding. He later died in the ICU because they couldn't keep his BP up. I am wondering if I should have reported the low ostomy output earlier and if I had if the MD would have ordered the KUB earlier. I didn't call because I didn't see a big change in the pt's condition and MD was already aware of the other symptoms. I am wondering if the pt really did have an ileus if I could have helped it be detected sooner and prevented this bad outcome, or if what happened was probably something sudden like peritonitis or perforation, or even shock due to so much fluid leaking out of the cardiovascular system. I am curious why the MD did not want us to put in an NG tube and if this would have been beneficial. Should I have immediately reported this low output and would it have made a difference? This is driving me crazy! Thank you for your help and sorry for the long post!


Category: Gastroenterologist, Surgical

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Category: Gastroenterologist, Surgical
Dr. Lokesh HM is online now

Expert:  Dr. Lokesh HM replied 4 Days.

Hello and thankyou for approaching DoctorSpring with your query.
I am sorry for your patient
Earlier Reporting of low output from ileostomy may have benefited the patient. However ileostomy output was just marginally decreased and hence earlier reporting would not have made a major difference in the final outcome of the patient.
Again NG tube should have been placed once the patient had vomiting, pain abdomen and distension. I don't know why your MD didn't ordered for it. Probably he might have thought distension might be due to ascites.
Patient might have developed intestinal obstruction or paralytic ileus, or even perforation peritonitis as the actions were delayed in an already a compromised patient, this might have been the cause for all sudden events. The MD must have had his reasons, clinical findings and judgements in taking the treatment call.

I hope this has helped.

Feel free to follow up. Thankyou
Thanks

Dr. Lokesh


Patient replied :

Thanks for your help! I keep thinking if I had reported the low output earlier the MD may have ordered the KUB earlier, but the other nurses told me he would probably have just watched the output overnight and ordered it the next day anyway. I thought the output may have been decreased because the patient was not eating, but does intake affect the amount of output? Others have said pt was headed for a bad outcome anyway after he refused the PEG tube but I am just wondering if there is anything I could have done differently


Expert:  Dr. Lokesh HM replied 3 Days.

Hi,
Ileostomy output will be less if patient is not taking orally, but it will not be 200ml in 24hrs. It may be some where around 400 to 500ml.
I don't think you could have something better than this, possibly your MD knew that patient had grave prognosis, he reacted like that.

Regards


Dr. Lokesh HM
Category: Gastroenterologist, Surgical
Experience: 
Fellowship: Minimal Access Surgery (FMAS)
Fellowship: Pancreato-Biliary surgery (FPBS), SGPGI Lucknow, 2012
Senior Residency: MCh, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGI) Lucknow, 2011
Junior Residency: MS, PGIMER, Chandigarh, 2008
Medical School: MBBS, MS from Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh, 2007
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